ED Patient Escapes Restraint: Bad Outcome? Expect Suit!

After a patient on a psychiatric hold managed to escape restraints, he ran out of the emergency department (ED) and was hit by a truck.

"It was a nightmare situation for everybody," says Derek S. Davis, JD, an attorney with Cooper & Scully in Dallas, TX, who defended the emergency physician (EP) named in the resulting malpractice lawsuit.

The patient was brought in by ambulance because he had crashed a company vehicle in an apparent suicide attempt, and was non-responsive during the EP's assessment.

The patient — a well-built, athletic individual — was placed in a treatment room with a security guard stationed outside the door. At one point, he suddenly jumped up and shoved the guard aside.

"He made a beeline for the exit door. The security guard gave chase, but the patient outdistanced him easily," says Davis. "Shortly after, the patient was found on the highway, hit by a Mack truck." The lawsuit filed by the family against the EP and the hospital included these allegations:

• The EP should have chemically restrained the patient.

The defense argued that based on the patient's behavior, he didn't meet criteria for chemical restraints, says Davis.

• The EP should not have placed the patient in a room next to the ED's exit.

The defense countered that this was the only room with a single exit point in the community ED. The plaintiff brought in a security expert from a large health care system to testify about the steps EPs typically take to determine which room to place a patient in.

"What we found was there is a wide disparity in terms of standard of care, in terms of how well-prepared hospitals are to deal with these issues," says Davis.

• The EP failed to communicate to security that the patient was a flight risk.

"The EP said, Of course I communicated that.' But we had absolutely no proof of it," says Davis. "The overall feel of the case was that the doctors just assumed the patient wasn't really a flight risk, and that they were duped."

Although the case was overall very defensible, the EP ended up settling. "From a defense standpoint, the EP had a tough time under the looks bad' factor," he explains.

Since the patient committed suicide, in ordinary circumstances, a jury would be tempted to place a significant amount, if not all of the blame, on the patient. This would have set the bar quite high for the family to prove negligence.

"But here, because of the [state's] involuntary commitment statute, the opposing attorney actually sought a presumption of negligence against the EP — because the very point of the statute was to prevent suicide," says Davis.

While the EP would ordinarily benefit from a jury's perception that suicide is an individual's choice that cannot always be prevented or predicted, here, the opposite presumption was in play, he explains.

Davis says that when dealing with a restrained patient, EPs should ask themselves this question: "If this patient runs out the door and commits suicide or harms somebody else, where am I weak? What didn't I do?"

Criteria Not Met

Another malpractice case involved a 17-year-old boy with a psychiatric history who was brought to an ED by the sheriff for evaluation after he was found standing on a roof threatening to kill himself. Initially, the patient was very cooperative.

"The EP had seen him, he was medically clear, and he was in a room with a security guard outside the door," says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA, who reviewed the claim.

While being escorted to the bathroom, the young man threw a blanket over the guard's face, bolted out the door, and jumped over a fence outside the ED, falling 60 feet to his death.

"The family sued. The hospital was dismissed, and the EP settled for a small amount because a couple of things were well documented," says Lawrence.

The central issue in the malpractice case was why the EP did not restrain the patient. "The EP's documentation clearly indicated that the patient needed no physical restraint because he didn't meet any of the criteria," says Lawrence.

The chart stated that the patient was awake, alert, oriented, cooperative, agreed not to leave the ED, and made no attempts to do so.

While a patient who is restrained while waiting for a psychiatric evaluation could sue the EP for assault and battery or false imprisonment, acknowledges Lawrence, such a suit is unlikely to be successful as long there is good documentation of the need for restraint.

Similarly, if the EP scrupulously documents why the patient was not restrained, such as the fact that the patient is cooperative and following instructions, "if something bad should happen to the patient, you are well covered," says Lawrence.

Consult Psychiatrist

While EPs can give medications for acute behavior control when patients present a risk to themselves or others, says Lawrence, if the EP starts chronic psychiatric treatment in the ED without consulting a psychiatrist, the EP could be held to a higher legal standard of care.

"It would be helpful if a psychiatrist on staff sees the patient in the ED, even if the patient can't be placed in a psychiatric facility," says Lawrence. "Even a documented phone call to a psychiatrist is better than the EP starting treatment on their own."

One exception, says Lawrence, is if the patient has well-documented psychiatric care and the EP is simply resuming the patient's prior medications.

"I don't think you are going out on a limb by doing that," he says. "After 24 hours or so, the medications might work to a point where the patient doesn't have to be hospitalized."

Other than resuming prior medications or administering medications to treat acute psychiatric symptoms, however, "it's probably best not to start anything chronic in the ER without consulting a psychiatrist," says Lawrence.